The elements of a hospital influenza pandemic preparedness plan discussed below are listed in the Hospital Preparedness Checklist provided in Appendix 2.
a) Hospital surveillance
• Hospital surveillance for novel strains of influenza
During the Interpandemic and Pandemic Alert Periods, healthcare providers and healthcare facilities play an essential role in surveillance for suspected cases of infection with novel strains of influenza and should be on the alert for such cases. Novel strains may include avian or animal influenza strains that can infect humans (like avian influenza A
4 Health care safety net providers deliver care to low-income and other vulnerable populations, including the uninsured and those covered by Medicaid. Many of these providers have either a legal mandate or an explicit policy to provide services regardless of a patient's ability to pay (http://www.ahcpr.gov/data/safetynet/faq.htm). Major safety net providers include public hospitals and community health centers as well as teaching and community hospitals, and private physicians.
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HHS Pandemic Influenza Plan[H5N1]) and new or re-emergent human viruses that cause cases or clusters of human disease. For detection of cases during the Interpandemic and Pandemic Alert Periods, hospitals should have:
• Procedures in place to facilitate laboratory testing on-site using proper biosafety levels and reporting of unusual influenza isolates through local and state health department channels (see Supplement 1). If appropriate methods or biosafety levels do not exist at the hospital, specimens should be shipped to the state health department.
• Predetermined thresholds for activating pandemic influenza surveillance plans (see S3-III.A and the Table).
• Hospital surveillance for pandemic influenza
During the Pandemic Period, healthcare providers and healthcare facilities will play an essential role in pandemic influenza surveillance (see Supplement 1). For detection of cases during the Pandemic Period, hospitals should have:
• Mechanisms for conducting surveillance in emergency departments to detect any increases in influenza-like illness (see box below) during the early stages of the pandemic
• Mechanisms for monitoring employee absenteeism for increases that might indicate early cases of pandemic influenza
• Mechanisms for tracking emergency department visits and hospital admissions and discharge of suspected or laboratory-confirmed pandemic influenza patients. This information will be needed to: 1) support local public health personnel in monitoring the progress and impact of the pandemic, 2) assess bed capacity and staffing needs, and 3) detect a resurgence in pandemic influenza that might follow the first wave of cases.
• Updated information on the types of data that should be reported to state or local health departments (e.g., admissions; discharges/deaths; patient characteristics such as age, underlying disease, and secondary complications;
illnesses in healthcare personnel) and plans for how these data will be collected during a pandemic. State and local health departments will provide guidance on the scope and mechanism of reporting (see Supplement 1).
• Criteria for distinguishing pandemic influenza from other respiratory diseases (see Supplement 5).
Symptoms of influenza include fever, headache, myalgia, prostration, coryza, sore throat, and cough. Nausea and vomiting are also commonly reported among children. Typical influenza (or “flu-like”) symptoms, such as fever, may not always be present in elderly patients, young children, patients in long-term care facilities, or persons with underlying chronic illnesses (see Supplement 5, Box 2).
b) Hospital communications
Each hospital should work with public health officials, other government officials, neighboring healthcare facilities, the lay public, and the press to ensure rapid and ongoing information-sharing during an influenza pandemic.
• External communications
• Assign responsibility for external communication about pandemic influenza; identify a person responsible for updating public health reporting (e.g., infection control), a clinical spokesperson (e.g., medical director), and a media spokesperson (e.g., public information officer).
• Identify points of contact among local media (e.g., newspaper, radio, television) representatives and public officials and community leaders.
• With guidance from state or local health departments, determine the methods, frequency, and scope of external communications.
• Determine how communications between local and regional healthcare facilities will be handled.
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• Consult with state or local health departments on plans for coordinating or facilitating communication among healthcare facilities. In the absence of such a plan, consider organizing a meeting of local health facilities to determine an optimal communications strategy.
• Identify key topics for ongoing communication (e.g., staffing needs, bed capacity, durable and consumable medical equipment and device needs, supplies of influenza vaccine and antiviral drugs).
• Assign responsibility within the hospital for communications with other healthcare facilities.
• Consult with local or state public health officials regarding the hospital’s role in communicating with the media and the public.
• Determine the type of hospital-specific communications (e.g., press releases, community bulletin board) that might be needed, and develop templates for these materials.
• Consult with local or state health departments on plans for a pandemic influenza hotline and/or website for public inquiries.
• Determine how public inquiries will be handled (e.g., refer callers to the health department; provide technical support for handling calls).
• Identify the types of information that will be provided by the hospital and the types of inquiries that will be referred to state or local health departments.
• Internal communications
• Determine how to keep administrators, personnel (including infection control staff and intake and triage staff), patients, and visitors informed of the ongoing impact of pandemic influenza on the facility and on the community.
c) Education and training
Each hospital should develop an education and training plan that addresses the needs of staff, patients, family members, and visitors. Hospitals should assign responsibility for coordination of the pandemic influenza education and training program and identify training materials—in different languages and at different reading levels, as needed—from HHS agencies, state and local health departments, and professional associations (see Appendix 1).
• Staff Education
• Identify educational resources for clinicians, including federally sponsored teleconferences, state and local health department programs, web-based training materials, and locally prepared presentations.
• General topics for staff education should include:
• Prevention and control of influenza
• Implications of pandemic influenza
• Benefits of annual influenza vaccination
• Role of antiviral drugs in preventing disease and reducing rates of severe influenza and its complications
• Infection control strategies for the control of influenza, including respiratory hygiene/cough etiquette, hand hygiene, standard precautions, droplet precautions, and, as appropriate, airborne precautions (see Supplement 4).
• Hospital-specific topics for staff education should include:
• Policies and procedures for the care of pandemic influenza patients, including how and where pandemic influenza patients will be cohorted
• Pandemic staffing contingency plans, including how the facility will deal with illness in personnel
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HHS Pandemic Influenza Plan• Policies for restricting visitors and mechanisms for enforcing these policies
• Reporting to the health department suspected cases of infection caused by novel influenza strains during the Interpandemic and Pandemic Alert Periods
• Measures to protect family and other close contacts from secondary occupational exposure
• Establish a schedule for training/education of clinical staff and a mechanism for documenting participation. Consider using annual infection control updates/meetings, medical Grand Rounds, and other educational venues as opportunities for training on pandemic influenza.
• Cross-train clinical personnel, including outpatient healthcare providers, who can provide support for essential patient-care areas (e.g., emergency department, ICU, medical units).
• Train intake and triage staff to detect patients with influenza symptoms and to implement immediate containment measures to prevent transmission (see also Supplement 5).
• Supply social workers, psychologists, psychiatrists, and nurses with guidance for providing psychological support to patients and hospital personnel during an influenza pandemic (see Supplement 11). (HHS agencies will identify or develop educational materials on: signs of distress, traumatic grief, stress management and effective coping strategies, building and sustaining personal resilience, and behavioral and psychological support resources.) If feasible, hospitals should also provide psychological-support training to appropriate individuals who are not mental health professionals (e.g., primary-care clinicians, leaders of community and faith-based organizations).
• Develop a strategy for “just-in-time” training of non-clinical staff who might be asked to assist clinical personnel (e.g., help with triage, distribute food trays, transport patients), students, retired health professionals, and volunteers who might be asked to provide basic nursing care (e.g., bathing, monitoring of vital signs); and other potential in-hospital caregivers (e.g., family members of patients).
• Education of patients, family members, and visitors
Patients and others should know what they can do to prevent disease transmission in the hospital, as well as at home and in community settings.
• Identify language-specific and reading-level appropriate materials for educating patients, family members, and hospital visitors during an influenza pandemic. If language-specific materials are not available for the population(s) being served, arrange for translations.
• Develop a plan for distributing information to all persons who enter the hospital. Identify staff to answer questions about procedures for preventing influenza transmission.
d) Triage, clinical evaluation, and admission procedures
During the peak of a pandemic, hospital emergency departments and outpatient offices might be overwhelmed with patients seeking care. Therefore, triage should be conducted to: 1) identify persons who might have pandemic influenza, 2) separate them from others to reduce the risk of disease transmission, and 3) identify the type of care they require (i.e., home care or hospitalization) (see Supplement 5).
• Develop a strategy for triage, diagnosis, and isolation of possible pandemic influenza patients. Consider the following triage mechanisms:
• Using phone triage to identify patients who need emergency care and those who can be referred to a medical office or other non-urgent facility
• Assigning separate waiting areas for persons with respiratory symptoms
• Assigning a separate triage evaluation area for persons with respiratory symptoms
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• Assigning a “triage coordinator” to manage patient flow, including deferring or referring patients who do not require emergency care (see Supplement 4 and Supplement 5).
• Review procedures for the clinical evaluation of patients in the emergency department and in outpatient medical offices to facilitate efficient and appropriate disposition of patients.
• Review admission procedures and streamline them as needed to limit the number of patient encounters in the hospital (e.g., direct admission to an inpatient bed).
• Identify a “trigger” point at which screening for signs and symptoms of pandemic influenza in all persons entering the hospital will escalate from passive (e.g., signs at the entrance) to active (e.g., direct questioning). In addition to visual alerts, potential screening measures might include priority triage of persons with respiratory symptoms and telephone screening of patients with appointments.
e) Facility access
Hospitals should determine in advance the criteria and procedures they will use to limit access to the facility if pandemic influenza spreads through the community.
• Define “essential” and “non-essential” visitors with regard to the hospital and the population served. Develop protocols for limiting non-essential visitors.
• Develop criteria or “triggers” for temporary closing of the hospital to new admissions and transfers. The criteria should consider staffing ratios, isolation capacity, and risks to non-influenza patients. As part of this effort, hospital administrators should: 1) determine who will make decisions about temporary closings and how and to whom these decisions will be communicated, and 2) consult with state and local health departments on their roles in determining policies for hospital admissions and transfers.
• Determine how to involve hospital security services in enforcing access controls. Consider meeting with local law enforcement officials in advance to determine what assistance, if any, they can provide. Note that local law enforcement might be overburdened during a pandemic and have limited ability to assist healthcare facilities with security services.
f) Occupational health
The ability to deliver quality health care is dependent on adequate staffing and optimum health and welfare of staff. During a pandemic,5the healthcare workforce will be stressed physically and psychologically. Like others in the community, many healthcare workers will become ill. Healthcare facilities must be prepared to: 1) protect healthy workers from exposures in the healthcare setting through the use of recommended infection control measures; 2) evaluate and manage symptomatic and ill healthcare personnel; 3) distribute and administer antiviral drugs and/or vaccines to healthcare personnel, as recommended by HHS and state health departments; and 4) provide psychosocial services to health care workers and their families to help sustain the workforce.
• Managing ill workers
• Establish a plan for detecting signs and symptoms of influenza in healthcare personnel before they report for duty.
• Develop policies for managing healthcare workers with respiratory symptoms that take into account HHS recommendations for healthcare workers with influenza (see www.cdc.gov/ncidod/hip/GUIDE/infectcont98.htm
• Consider assigning staff who are recovering from influenza to care for influenza patients.
5During the Pandemic Alert Period, healthcare personnel exposed to avian influenza A (H5N1) or other novel strains of influenza should be managed on a case-by-case basis (see Supplement 5).
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• Time-off policies
Ensure that time-off policies and procedures consider staffing needs during periods of clinical crisis.
• Reassignment of high-risk personnel
Establish a plan to protect personnel at high risk for complications of influenza (e.g., pregnant women, immunocompromised persons) by reassigning them to low-risk duties (e.g., non-influenza patient care, administrative duties that do not involve patient care) or placing them on furlough.
• Psychosocial health services (see also Supplement 11)
• Identify mental health and faith-based resources for counseling of healthcare personnel during a pandemic.
Counseling should include measures to maximize professional performance and personal resilience by addressing management of grief, exhaustion, anger, and fear; physical and mental health care for oneself and one’s loved ones;
and resolution of ethical dilemmas.
• Determine a strategy for supporting healthcare workers’ needs for rest and recuperation.
• Develop a strategy for housing and feeding healthcare personnel who might be needed on-site for prolonged periods
• Develop a strategy for accommodating and supporting staff who have child- or elder-care responsibilities.
• Influenza vaccination and use of antiviral drugs
• Promote annual influenza vaccination among hospital employees. Increased vaccination coverage during the Interpandemic Period might help increase vaccine acceptance during a pandemic and will limit the spread of seasonal influenza.
• Ensure that a system is in place for documenting influenza vaccination of healthcare personnel. The hospital might decide to enroll in the National Healthcare Safety Network (NHSN; www.cdc.gov/ncidod/hip/NNIS/members/
nhsn.htm) to help track employee vaccination and health status.
• Establish a strategy for rapidly vaccinating or providing antiviral prophylaxis or treatment to healthcare personnel as recommended by HHS and state health departments. Preliminary recommendations on the use of antiviral drugs and vaccination have been established (see Part 1, Appendix E and Supplement 6 and Supplement 7) but will need to be tailored to fit the epidemiology of the pandemic.
g) Use and administration of vaccines and antiviral drugs
• Pandemic influenza vaccine and “pre-pandemic” influenza vaccine
Once the characteristics of a new pandemic influenza virus are identified, the development of a pandemic vaccine will begin. Recognizing that there may be benefits to immunization with a vaccine prepared before the pandemic against an influenza virus of the same subtype, efforts are underway to stockpile vaccines for subtypes with pandemic potential.
As supplies of these vaccines become available, it is possible that some healthcare personnel and others critical to a pandemic response will be recommended for vaccination to provide partial protection or immunological priming for a pandemic strain. Policies for the use of pre-pandemic vaccine have not been finalized.
• Interim recommendations on priority groups for vaccination and strategies for vaccine distribution are discussed in Supplement 6. During a pandemic, these recommendations will be updated, taking into account populations which are most at risk. In the interim, healthcare facilities should:
• Monitor updated HHS information and recommendations on the development, distribution, and use of a pandemic influenza vaccine (http://www.pandemicflu.gov)
• Work with local and state health departments on plans for distributing pandemic influenza vaccine.
• Provide estimates of the quantities of vaccine needed for hospital staff and patients, as requested by the state health department.
HHS Pandemic Influenza Plan
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• Develop a stratification scheme for prioritizing vaccination of healthcare personnel who are most critical for patient care and essential personnel to maintain the day-to-day operation of the healthcare facility.
• Develop a pandemic influenza vaccination plan in the hospital.
• Antiviral drugs
Antiviral drugs effective against the circulating pandemic strain can be used for treatment and possibly prophylaxis during an influenza pandemic. Because of the effectiveness of treatment with antiviral drugs such as oseltamivir and zanamivir, and the greater efficiency of treatment in a setting of limited supply, the use of prophylaxis will be restricted to maximize health benefits. Interim recommendations for the use of antiviral drugs are discussed in Supplement 7.
Healthcare facilities should consider how antiviral drugs might be used in their patient and healthcare worker populations, taking into account state and national guidelines, and determine if a reserve supply should be stockpiled.
(See also HRSA cooperative agreements www.hrsa.gov/grants/preview/guidancespecial/hrsa05001.htm.) h) Surge capacity
Healthcare facilities should plan ahead to address emergency staffing needs and increased demand for isolation wards, ICUs, assisted ventilation services, and consumable and durable medical supplies (Box 2). Hospital planners can use FluSurge software (http://www.cdc.gov/flu/flusurge.htm) to estimate the potential impact of a pandemic on resources such as staffed beds (both overall and ICU) and ventilators (see also HRSA and AHRQ planning and surge capacity resources listed in Appendix 1.)
• Staffing
• Assign responsibility for the assessment and coordination of staffing during an emergency.
• Estimate the minimum number and categories of personnel needed to care for a single patient or a small group of patients with influenza complications on a given day.
• Determine how the hospital will meet staffing needs as the number of patients with pandemic influenza increases and/or healthcare and support personnel become ill or remain at home to care for ill family members. Consider the following options:
• Assigning patient-care responsibilities to clinical administrators
• Recruiting retired healthcare personnel
• Using trainees (e.g., medical and nursing students)
• Using patients’ family members in an ancillary healthcare capacity
• Collaborate with local and regional healthcare-planning groups in an attempt to achieve adequate staffing of the hospital during an influenza pandemic (e.g., decide whether and how staff will be shared with other healthcare facilities, determine how salary issues will be addressed for employees shared between facilities, and consider ways to increase the number of home healthcare staff to reduce hospital admissions during the emergency). State and local health departments can help assess the feasibility of recruiting staff from different hospitals and/or regions, working in coordination with federal facilities, including Veterans Administration and Department of Defense hospitals. Healthcare facilities may implement these arrangements through Mutual Aid Agreements (MAAs) or Memoranda of Understanding/Agreement (MOU/As).
• Increase cross-training of personnel to provide support for essential patient-care areas at times of severe staffing shortages (e.g., in emergency departments, ICUs, or medical units) (see also S3-III.A.2.c).
• Create a list of essential-support personnel titles (e.g., environmental and engineering services, nutrition and food services, administrative, clerical, medical records, information technology, laboratory) that are needed to maintain hospital operations.
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• Create a list of non-essential positions that can be re-assigned to support critical hospital services or placed on administrative leave to limit the number of persons in the hospital.
• Consult with the state health department6 on plans for rapidly credentialing healthcare professionals during a pandemic. This might include defining when an “emergency staffing crisis” can be declared and identifying emergency laws that allow employment of healthcare personnel with out-of-state licenses.
• Identify insurance and liability issues related to the use of non-facility staff.
• Explore opportunities for recruiting healthcare personnel from other healthcare settings, (e.g., medical offices and day-surgery centers). Consult public health partners about existing state or local plans for recruitment and deployment of local personnel.
• Bed capacity
• Review and revise admissions criteria for times when bed capacity is limited (see also S3-III.A.2.e).
• Develop policies and procedures for expediting the discharge of patients who do not require ongoing inpatient care (e.g., develop plans and policies for transporting discharged patients home or to other facilities; create a patient
• Develop policies and procedures for expediting the discharge of patients who do not require ongoing inpatient care (e.g., develop plans and policies for transporting discharged patients home or to other facilities; create a patient